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OBJECTIVES: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) requires considerable human and financial resources. Few studies have focused on early mortality (ie, occurring within 72 hours after VA-ECMO implantation). The objective of this study was to establish a prognosis score-the IMPACT score (prediction of early mortality associated with VA-ECMO using preimplantation characteristics)-by determining the risk factors associated with early mortality. DESIGN: This was a retrospective and observational study. SETTING: The study was conducted at a University hospital. PARTICIPANTS: This single-center retrospective study included 147 patients treated with VA-ECMO for cardiogenic shock between 2014 and 2021. METHODS: The primary outcome was early mortality (ie, occurring within 72 hours after VA-ECMO implantation). Multivariate logistic regression was performed using a bootstrapping methodology to identify factors independently associated with early mortality. To construct the score, identified variables had points (pts) assigned corresponding to their odds ratio. RESULTS: A total of 147 patients were included in the study. Early mortality (<72 hours) was 26% (38 patients). Four variables were established: cardiac arrest (2 pts), lactate levels (3 pts), platelet count <100 g/L (4 pts), and renal-replacement therapy (5 pts). The IMPACT score had an area under the receiver operating characteristic curve of 0.78 (95% CI 0.86-0.70) to predict early mortality. CONCLUSIONS: In the authors' experience, 26% of patients treated with VA-ECMO presented early mortality. The IMPACT score is a reliable predictor of early mortality and may assist with VA-ECMO initiation decision-making.
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Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Humanos , Estudos Retrospectivos , Oxigenação por Membrana Extracorpórea/métodos , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/terapia , Mortalidade HospitalarRESUMO
OBJECTIVES: Anemia and transfusion are common in cardiac surgery patients, and are associated with significant morbidity and mortality. Multiple perioperative interventions have been described to reduce blood transfusion, but are rarely combined altogether. The aim of this study was to compare the incidence of red blood cell (RBC) transfusion in adult patients undergoing cardiac surgery before and after the implementation of a perioperative patient blood management (PBM) program. DESIGN: Before-and-after observational study. SETTING: Single-center French university teaching hospital. PARTICIPANTS: Adult patients scheduled for cardiac surgery. INTERVENTIONS: Perioperative patient blood management program including pre-, intra-, and postoperative interventions aimed at identifying and correcting anemia, minimizing blood loss during surgery, and optimizing coagulation. MEASUREMENTS AND MAIN RESULTS: Four hundred thirty-four patients were included in the study from January 2021 to July 2022. The incidence of perioperative RBC transfusion (intraoperatively and during the first 2 postoperative days) was significantly reduced from 43% (90/213) in the pre-PBM period to 27% (60/221) in the post-PBM period (p < 0.001). The application of a PBM program was associated with a reduction in perioperative RBC transfusion by multivariate analysis (odds ratio 0.55, 95% CI 0.36-0.85, p = 0.007), and was associated with a reduction in the median number of RBC units transfused within transfused patients (p = 0.025). These effects persisted at day 30 after surgery (p = 0.029). CONCLUSION: A perioperative PBM program in adult patients undergoing cardiac surgery was associated with a significant reduction in perioperative RBC transfusion, which persisted at day 30.
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Anemia , Procedimentos Cirúrgicos Cardíacos , Adulto , Humanos , Transfusão de Eritrócitos , Transfusão de Sangue , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Hospitais UniversitáriosRESUMO
OBJECTIVE: Current guidelines consider obesity to be a relative contraindication to venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. The authors investigated the effect of body mass index (BMI) on clinical outcomes in patients treated with VA-ECMO for cardiogenic shock. DESIGN: This was a retrospective and observational study. SETTING: University hospital. PARTICIPANTS: The study comprised 150 adult patients who underwent VA-ECMO for cardiogenic shock. MEASUREMENTS AND MAIN RESULTS: The primary outcome was intensive care unit (ICU) mortality. Of the 150 included patients, 10 were underweight (BMI < 18.5 kg/m²), 62 were normal weight (BMI = 18.5-24.9 kg/m²), 34 were overweight (BMI = 25.0-29.9 kg/m²), 34 were obese class I (BMI = 30.0-34.9 kg/m²), and 10 were obese class II (BMI = 35.0-39.9 kg/m²). All-cause ICU mortality was 62% (underweight, 70%; normal weight, 53%; overweight, 65%; class I obese, 71%; class II obese, 70%). After multivariate logistic regression, BMI was not associated with ICU mortality (adjusted odds ratio [aOR] 0.99 [0.92-1.07], p = 0.8). Analysis by BMI category showed unfavorable mortality trends in underweight patients (aOR 3.58 [0.82-19.6], p = 0.11) and class I obese patients (aOR 2.39 [0.95-6.38], p = 0.07). No statistically significant differences were found among BMI categories in the incidences of complications. CONCLUSION: The results suggested that BMI alone should not be considered an exclusion criterion for VA-ECMO. The unfavorable trend observed in underweight patients could be the result of malnutrition.
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Oxigenação por Membrana Extracorpórea , Choque Cardiogênico , Adulto , Índice de Massa Corporal , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Obesidade/complicações , Obesidade/epidemiologia , Sobrepeso/complicações , Estudos Retrospectivos , Choque Cardiogênico/etiologia , Magreza/complicações , Magreza/epidemiologiaRESUMO
A simplified delivery technique for the frozen elephant trunk procedure allows the distal suture to be performed on a perfused and loaded aorta in moderate hypothermia-or even normothermia-reducing circulatory arrest time to just a few minutes. Two surgical sealing tourniquets are placed around the aortic arch, usually between the brachiocephalic trunk (BCT) and the left common carotid artery and the aorta is cross-clamped and cardioplegia started. Once in mild hypothermia, the BCT is disconnected and circulatory arrest is initiated while cerebral perfusion is maintained. This modified technique can be used in all pathologies, including dissections.
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Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Dissecção Aórtica/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Humanos , Perfusão , Resultado do TratamentoRESUMO
Background: Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is an efficient ventilatory support in patients with refractory Covid-19-related Acute Respiratory Distress Syndrome (ARDS), however the duration of invasive mechanical ventilation (IMV) before ECMO initiation as a contraindication is still controversial. The aim of this study was to investigate the impact of prolonged IMV prior to VV-ECMO in patients suffering from refractory Covid-19-related ARDS. Methods: This single-center retrospective study included all patients treated with VV-ECMO for refractory Covid-19-related ARDS between January 1, 2020 and May 31, 2022. The impact of IMV duration was investigated by comparing patients on VV-ECMO during the 7 days (and 10 days) following IMV with those assisted after 7 days (and 10 days). The primary endpoint was in-hospital mortality. Results: Sixty-four patients were hospitalized in the ICU for Covid-19-related refractory ARDS requiring VV-ECMO. Global in-hospital mortality was 55 %. Median duration of IMV was 4 [2; 8] days before VV-ECMO initiation. There was no significant difference in in-hospital mortality between patients assisted with IMV pre-VV-ECMO for a duration of ≤7 days (≤10 days) and those assisted after 7 days (and 10 days) ((p = 0.59 and p = 0.45). Conclusion: This study suggests that patients assisted with VV-ECMO after prolonged IMV had the same prognosis than those assisted earlier in refractory Covid-19-related ARDS. Therefore, prolonged mechanical ventilation of more than 7-10 days should not contraindicate VV-ECMO support. An individual approach is necessary to balance the risks and benefits of ECMO in this population.
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Although performing total arterial coronary artery bypass revascularisation, using internal thoracic arteries as in situ grafts is not always feasible. The implantation of an internal thoracic artery on the aorta could be necessary, in a situation rarely planned preoperatively. Herein, we describe a simple and original way to perform this anastomosis. A 2-cm length of extra radial artery graft ended by a clip is anastomosed to the aorta in a standard fashion. The internal thoracic artery is then sown on the radial dome. We obtain a wide arterial anastomotic chamber using a standard technique, safe and easily reproducible.
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Artéria Torácica Interna , Humanos , Artéria Torácica Interna/diagnóstico por imagem , Artéria Torácica Interna/cirurgia , Aorta/diagnóstico por imagem , Aorta/cirurgia , Ponte de Artéria Coronária/métodos , Procedimentos Cirúrgicos Vasculares , Artéria Radial/cirurgia , Artéria Radial/transplanteRESUMO
OBJECTIVES: The aim of this study using decision curve analysis (DCA) was to evaluate the clinical utility of a deep-learning mortality prediction model for cardiac surgery decision making compared with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II and to 2 machine-learning models. METHODS: Using data from a French prospective database, this retrospective study evaluated all patients who underwent cardiac surgery in 43 hospital centers between January 2012 and December 2020. A receiver operating characteristic analysis was performed to compare the accuracy of the EuroSCORE II, machine-learning models, and an adapted Tabular Bidirectional Encoder Representations from Transformers deep-learning model in predicting postoperative in-hospital mortality. The clinical utility of these models for cardiac surgery decision making was compared using DCA. RESULTS: Over the study period, 165,640 patients underwent cardiac surgery, with a mean EuroSCORE II of 3.99 ± 6.67%. In the receiver operating characteristic analysis, the area under the curve was significantly greater for the deep-learning model (0.834; 95% confidence interval, 0.831-0.838) than the EuroSCORE II (P < .001), the random forest model (P = .03), and the Extreme Gradient Boosting model (P = .03). In the DCA, the clinical utility of the 3 artificial intelligence models was superior to that of the EuroSCORE II, especially when the threshold probability of death was high (>45%). The deep-learning model showed the greatest advantage over the EuroSCORE II. CONCLUSIONS: The deep-learning model had better predictive accuracy and greater clinical utility than the EuroSCORE II and the 2 machine-learning models. These findings suggest that deep learning with Tabular Bidirectional Encoder Representations from Transformers prediction model could be used in the future as the gold standard for cardiac surgery decision making.
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Procedimentos Cirúrgicos Cardíacos , Aprendizado Profundo , Humanos , Estudos Retrospectivos , Inteligência Artificial , Medição de Risco , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Mortalidade Hospitalar , Curva ROC , Tomada de DecisõesRESUMO
The clinical characteristics and epidemiology of Q fever in the Tropics are poorly described. We performed a retrospective cohort study of hospitalized cases between 2004 and 2017 in Reunion Island. Acute Q fever was defined in presence of a positive serology (phase II IgG ≥ 200 and phase II IgM ≥ 50), or a seroconversion (4-fold increase in phase II IgG between paired samples), or a positive PCR (blood or serum). Forty-two cases matched the diagnostic criteria. The most common clinical manifestations were fever (85.7%) and pulmonary symptoms (61.9%), including pneumonia (45.2%). Ninety percent of the patients were living in a farming area. Cumulative incidence was estimated at 9.3 per 100,000 inhabitants (95%CI: 6.4-12.1) with cases diagnosed yearly all throughout the study period except in 2006. Together with the seroprevalence figures, these data suggest that Q fever reaches low to moderate endemic levels on Reunion Island. As previously reported, pulmonary symptoms are in the foreground.
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BACKGROUND: Bartonella spp. are fastidious bacteria frequently identified as the cause of blood culture-negative (BCN) endocarditis. However, Bartonella infections are difficult to diagnose in routine laboratory testing and their incidence is probably underestimated. We investigated the epidemiological and clinical features of Bartonella endocarditis cases diagnosed between 2009 and 2021 on Reunion Island (Southwest Indian Ocean). METHOD: We retrospectively included all patients diagnosed with Bartonella endocarditis at Reunion Island University Hospital during this period. Endocarditis was diagnosed on the basis of microbiological findings, including serological tests (IFA) and PCR on cardiac valves, and the modified Duke criteria. We used then the multispacer typing (MST) method to genotype the available Bartonella strains. FINDINGS: We report 12 cases of B. quintana endocarditis on Reunion Island (83.3% in men, median patient age: 32 years). All the patients originated from the Comoros archipelago. The traditional risk factors for B. quintana infection (homelessness, alcoholism, exposure to body lice) were absent in all but two of the patients, who reported head louse infestations in childhood. Previous heart disease leading to valve dysfunction was recorded in 50% of patients. All patients underwent cardiac valve surgery and antimicrobial therapy with a regimen including doxycycline. All patients presented high C-reactive protein concentrations, anemia and negative blood cultures. The titer of IgG antibodies against Bartonella sp. exceeded 1:800 in 42% of patients. Specific PCR on cardiac valves confirmed the diagnosis of B. quintana endocarditis in all patients. Genotyping by the MST method was performed on four strains detected in preserved excised valves and was contributive for three, which displayed the MST6 genotype. CONCLUSIONS: Bartonella quintana is an important cause of infective endocarditis in the Comoros archipelago and should be suspected in patients with mitral valve dysfunction and BCN from this area.
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Bartonella quintana , Bartonella , Endocardite , Masculino , Humanos , Adulto , Bartonella quintana/genética , Oceano Índico , Estudos RetrospectivosRESUMO
Glomus tumors are rare, mostly benign, and often superficial tumors that commonly occur on the upper and lower extremities. Whereas other locations have been described in the literature, we report the first case of glomus tumor in the abdominal aorta in a 21-year-old patient.
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BACKGROUND: Few data are available on the impact of levosimendan in refractory cardiogenic shock patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). The aim of this study was to evaluate the impact of levosimendan on VA-ECMO weaning in patients hospitalized in intensive care unit (ICU). METHODS: This retrospective cohort study was conducted in a French university hospital from 2010 to 2017. All patients hospitalized in ICU undergoing VA-ECMO were consecutively evaluated. RESULTS: A total of 150 patients undergoing VA-ECMO were eligible for the study. Thirty-eight propensity-matched patients were evaluated in the levosimendan group and 65 in the non-levosimendan group. In patients treated with levosimendan, left ventricular ejection fraction had increased from 21.5 ± 9.1% to 30.7 ± 13.5% (P < 0.0001) and aortic velocity-time integral from 8.9 ± 4 cm to 12.5 ± 3.8 cm (P = 0.002) 24 h after drug infusion. After propensity score matching, levosimendan was the only factor associated with a significant reduction in VA-ECMO weaning failure rates (hazard ratio = 0.16; 95% confidence interval 0.04-0.7; P = 0.01). Kaplan-Meier survival curves showed that survival rates at 30 days were 78.4% for the levosimendan group and 49.5% for the non-levosimendan group (P = 0.02). After propensity score matching analysis, the difference in 30-day mortality between the two groups was not significant (hazard ratio = 0.55; 95% confidence interval 0.27-1.10; P = 0.09). CONCLUSIONS: Our results suggest that levosimendan was associated with a beneficial effect on VA-ECMO weaning in ICU patients.
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Little is known about cannula-related infection (CRI) in patients supported by extracorporeal membrane oxygenation (ECMO). The aim of this study was to assess the incidence, the risk factors, prognosis, and microbiological characteristics of CRI in patients supported by ECMO. This retrospective cohort study was conducted in one intensive care unit (ICU). Among 220 consecutive patients with peripheral ECMO, 39 (17.7%) developed CRI. The incidence of CRI was 17.2 per 1,000 ECMO days. The main isolated microorganisms were Enterobacteriaceae (38%), Staphylococcus spp. (28.2%; 8.5% were methicillin-sensitive Staphylococcus aureus and 19.7% were coagulase-negative staphylococci), and Pseudomonas aeruginosa (18.3%). Bacteremia was present in 23 cases (59.7%). In multivariate analysis, the risk factors for CRI were longer ECMO duration (p = 0.006) and higher Simplified Acute Physiology Score 2 (p = 0.004). Forty-one percentage of patients with CRI needed surgical management of the infected site. Cannula-related infection was not associated with higher in-hospital mortality (p = 0.73), but it was associated with a longer stay in ICU (p < 0.0001) and a longer stay in hospital (p = 0.002). In conclusion, CRI is frequent in patients with ECMO and associated with a longer stay in hospital. Risk factors for CRI were longer ECMO duration and higher Simplified Acute Physiology Score 2. Concomitant bacteremia was frequent (59.7%) and CRI should be strongly investigated in cases of positive blood culture.
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Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/microbiologia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Adulto , Bacteriemia/epidemiologia , Bacteriemia/etiologia , Bacteriemia/microbiologia , Cânula/efeitos adversos , Cânula/microbiologia , Infecções Relacionadas a Cateter/etiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de RiscoRESUMO
A 19-year-old man with mitral valve endocarditis and prolapse, intracerebral and intracerebellar hematoma, and a mycotic cerebral aneurysm underwent emergency mitral valve replacement during minimal cardiopulmonary bypass (total priming volume, 800 mL; autologous retropriming, activated clotting time <300 seconds) 1 day after undergoing endovascular coil embolization of the aneurysm. Postoperatively, there were no extensions of the intracerebral and intracerebellar hematoma. After intensive rehabilitation therapy, the patient recovered fully except for residual bilateral claudication because of preoperative bilateral embolism to both superficial femoral arteries.
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BACKGROUND: There is no heart transplantation centre on the French overseas territory of Reunion Island (distance of 10,000 km). The aim of this study was to describe the characteristics of cardiogenic shock adult patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) who were transferred from Reunion Island to mainland France for emergency heart transplantation. METHODS: This retrospective observational study was conducted between 2005 and 2015. The characteristics and outcome of cardiogenic shock patients on VA-ECMO were compared with those of cardiogenic shock patients not on VA-ECMO. RESULTS: Thirty-three cardiogenic shock adult patients were transferred from Reunion Island to Paris for emergency heart transplantation. Among them, 19 (57.6%) needed mechanical circulatory support in the form of VA-ECMO. Median age was 51 (33-57) years and 46% of the patients had ischaemic heart disease. Patients on VA-ECMO presented higher Sequential Organ Failure Assessment score ( p = 0.03). No death occurred during the medical transfer by long flight, while severe complications occurred in 10 patients (30.3%). Incidence of thromboembolic events, severe infectious complications and major haemorrhages was higher in the group of patients on VA-ECMO than in the group of patients not on VA-ECMO ( p <0.01). Seven patients from the VA-ECMO group (36.8%) and six patients from the non-VA-ECMO group (42.9%, p=0.7) underwent heart transplantation after a median delay of 10 (4-29) days on the emergency waiting list. After heart transplantation, one-year survival rates were 85.7% for patients on VA-ECMO and 83.3% for patients not on VA-ECMO ( p=0.91). CONCLUSIONS: This study suggests the feasibility of very long-distance medical evacuation of cardiogenic shock patients on VA-ECMO for emergency heart transplantation, with acceptable long-term results.
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Emergências , Oxigenação por Membrana Extracorpórea/métodos , Transplante de Coração , Transferência de Pacientes/métodos , Choque Cardiogênico/terapia , Adulto , Feminino , Seguimentos , França/epidemiologia , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Reunião/epidemiologia , Choque Cardiogênico/epidemiologia , Taxa de Sobrevida/tendênciasRESUMO
Even though alcoholism is a major health concern, alcoholic cardiomyopathy is a little-known pathology. The exact prevalence remains elusive (20-40% of dilated cardiomyopathy). However, it can lead to dilated cardiomyopathy, heart failure and refractory cardiogenic shock. The literature on cardiogenic shock in alcoholic cardiomyopathy is limited. We report 4 cases of patients with refractory cardiogenic shock due to heavy alcohol consumption, who were treated with venoarterial extracorporeal membrane oxygenation. The evolution was favourable with recovery in 3 patients and the need for heart transplantation in 1 patient. After 3-5 years, all patients are alive, 2 of 4 are sober, all of them are on cardiac follow-up and none of them have presented with a cardiac relapse.
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Cardiomiopatia Alcoólica/complicações , Oxigenação por Membrana Extracorpórea/métodos , Choque Cardiogênico/cirurgia , Adulto , Cardiomiopatia Alcoólica/diagnóstico , Cardiomiopatia Alcoólica/cirurgia , Ecocardiografia , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Choque Cardiogênico/etiologia , Adulto JovemRESUMO
PURPOSE: Few data are available on the potential benefits and risks of red blood cell transfusion in patients undergoing extracorporeal membrane oxygenation. The aim of this study was to identify the determinants and prognosis of red blood cell transfusion in patients undergoing extracorporeal membrane oxygenation, with a special focus on biological parameters during extracorporeal membrane oxygenation treatment. METHODS: We conducted a single-center retrospective cohort study including all consecutive patients who underwent extracorporeal membrane oxygenation between January 2010 and December 2015. RESULTS: The 201 evaluated patients received a median of 0.9 [0.5-1.7] units of red blood cell per day. Significant and clinically relevant variables that best correlated with units of red blood cell transfused per day of extracorporeal membrane oxygenation were lower median daily prothrombin time in percentage (Quick) ( t = -0.016, p < 0.0001), higher median daily free bilirubin level ( t = 0.016, p < 0.0001), and lower pH ( t = -2.434, p < 0.0001). In multivariate analysis, red blood cell transfusion was associated with a significantly higher rate of in-intensive care unit mortality (per red blood cell unit increment; adjusted odds ratio: 1.07, 95% confidence interval: 1.02-1.12, p = 0.005). It was also associated with higher rates of acute renal failure ( p = 0.025), thromboembolic complications ( p = 0.0045), and sepsis ( p = 0.015). CONCLUSION: This study suggests that red blood cell transfusion may be associated with a higher mortality rate and with severe complications. However, we cannot conclude a direct causal relationship, as red blood cell transfusion may be only a marker of poor outcome. We recommend that physicians correct acidosis and hemolysis in patients undergoing extracorporeal membrane oxygenation whenever possible.
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Transfusão de Eritrócitos , Oxigenação por Membrana Extracorpórea , Injúria Renal Aguda/epidemiologia , Estudos de Coortes , Feminino , França/epidemiologia , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Prognóstico , Tempo de Protrombina , Estudos Retrospectivos , Sepse/epidemiologia , Tromboembolia/epidemiologiaRESUMO
Recent series reported excellent results of surgical embolectomy in patients with acute pulmonary embolism with mortality rates of about 5-9% (range 0-13%). However, very low mortality of patients receiving medical treatment for intermediate-risk pulmonary embolism (1.5 and 2.8% at 7 and 30 days, respectively) was recently reported. Thus, we would like to challenge the indication for surgical embolectomy in the subset of intermediate-risk patients.
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Embolectomia , Embolia Pulmonar/terapia , Terapia Trombolítica , Doença Aguda , Embolectomia/efeitos adversos , Embolectomia/mortalidade , Humanos , Seleção de Pacientes , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Embolia Pulmonar/cirurgia , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Resultado do TratamentoRESUMO
Allogeneic hematopoietic stem-cell transplantation (HSCT) is the treatment of choice for many malignant and nonmalignant hematologic disorders. Donor T cells present in the hematopoietic stem-cell transplant improve engraftment and immune reconstitution and contribute to the graft-versus-leukemia effect, but are also responsible for the life-threatening graft-versus-host disease (GVHD). CD4(+)CD25(+) immunoregulatory T cells, which play a pivotal role in preventing organ-specific diseases, can also modulate GVHD if administered in equal numbers of T cells at the time of grafting. In this article, the authors describe a procedure of ex vivo selection and expansion of regulatory T cells specific for recipient-type alloantigens. These expanded regulatory T cells controlled GVHD. Their therapeutic use in HSCT should allow specific suppression of the activation of donor alloreactive T cells involved in GVHD while preserving the beneficial effects of other T cells.
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Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD4-Positivos/transplante , Doença Enxerto-Hospedeiro/etiologia , Doença Enxerto-Hospedeiro/terapia , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Isoantígenos/imunologia , Receptores de Interleucina-2/metabolismo , Transplante Homólogo/efeitos adversos , Animais , HumanosRESUMO
This study examines the incidence, predictors, and evolution of postoperative atrioventricular block (AVB) after mitral valve repair (MVR) in 115 consecutive patients using Carpentier's technique (between November 1996 and April 1997). Postoperative AVB occurred in 27 patients (23%). Third-degree AVB was found in 7 patients (6%) in the immediate postoperative period, but in 4 it was transient, resolving partially or completely before the seventh postoperative day. Second-degree AVB (Mobitz type I) occurred in 4 patients (3%) immediately after operation and resolved in all before hospital discharge. Isolated first-degree AVB occurred in 16 patients (14%) and was permanent in 12. Neither the preoperative variables nor the mitral procedures including anterior versus posterior leaflet repair were related to postoperative AVB. A lesser systemic hypothermia during surgery was the only, modestly independent predictor of postoperative AVB (odds ratio 1.53; 95% confidence interval 1.04 to 2.25; p = 0.031). Three patients (2.6%) had permanent pacemaker implantation, on average 18 days after operation, and all had persistent third-degree AVB. With a mean follow-up of 3 years, no recurrence or worsening of conduction disturbances, no further pacemaker implantation, and no late deaths were observed.
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Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Bloqueio Cardíaco/etiologia , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Eletrocardiografia , Feminino , Seguimentos , Bloqueio Cardíaco/diagnóstico , Bloqueio Cardíaco/fisiopatologia , Sistema de Condução Cardíaco/fisiopatologia , Humanos , Hipotermia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Marca-Passo Artificial , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Remissão Espontânea , Volume Sistólico , Taxa de Sobrevida , Resultado do TratamentoRESUMO
We report the case of a 49-year-old woman who experienced an inferior myocardial infarction with right ventricular extension, poorly tolerated, partly due to a severe rheumatic mitral stenosis discovered during the hospitalization. Following an initial emergent mechanical circulatory support with femoro-femoral extracorporeal life support (ECLS), the patient had the mitral valve replaced, and the arterio-venous ECLS was removed for a right ventricular assistance device. After seven weeks, she was discharged and fully recovered.